MDS Alert

Published on Fri Jun 26, 2009 PDF

Follow these inside tips to boost accuracy.

Painting an inaccurate picture of residents' skin ulcers on the MDS can paint your facility into a corner rife with numerous potential F tags.

Miscoding ulcers in Section M can also skew your payment.

The good news: You can cut through the coding confusion with this combination of assessment and coding strategies for Section M.

1. Make sure you have the right wound diagnosis before you code. Only a physician or clinician whose license allows him or her to diagnose can diagnose a wound, notes Rena Shephard, MHA, RN, RAC-MT, C-NE, president and CEO of RRS Healthcare Consulting Services in San Diego, and founding chair and executive editor for the American Association of Nurse Assessment Coordinators. Yet, in some cases, a licensed nurse will call for a treatment order for what the nurse believes to be a pressurerelated wound, observes Shephard.

Then the treatment order says it's for a pressure ulcer -- and there's the diagnosis, which the nurse actually gave to the physician.

2. Do as the RAI manual -- not the MDS form -- instructs for M1. The MDS form still says to code ulcers at M1 regardless of their cause, Shephard notes. But the RAI Manual has been updated for a long time to say you only code wounds in M1 that are related to pressure and/or circulatory problems, she adds. Thus, you would stage and code pressure ulcers, as well as venous and arterial ulcers in Section M1. "M2 is a subset of M1," Shephard says, where you code pressure ulcers at M2a, and venous ulcers at M2b.

Computer coding tip: You only code venous or pressure ulcers in M2. And if your software vendor has an edit that doesn't allow M2 to be zero when M1 has a value, the facility would be required to report a pressure or venous ulcer when the resident didn't have one, cautions Peter Arbuthnot, an MDS software expert in Jackson, Miss. If that's the case with your software, let your vendor know, advised the Centers for Medicare & Medicaid Services at a SNF/LTC Open door Forum.

3. Know how to code diabetic ulcers. The MDS 2.0 doesn't include a place for you to code a diabetic ulcer, observes Evonne Fillinger, RN, BSN, WCC, RAC-CT, a clinical operations consultant with Boyer & Associates in Brookfield, Wis.

Code a diabetic ulcer in M1 if it has a pressure or circulatory component, advises Shephard. For example, she would code a diabetic ulcer caused by pressure due to shoes as a pressure ulcer. "People with diabetes can also get arterial or venous ulcers.

Again, the physician or clinician who can diagnose wounds should diagnose the underlying etiology."

The other place to code a diabetic ulcer is in M6 (open lesions on the foot), directs Joan Brundick, RN, the state RAI coordinator for Missouri. In all cases, the care plan should identify and address the diabetic ulcer, emphasizes Brundick.

4. Downstage ulcers on the MDS as they heal. If you don't, the SNF could end up receiving inappropriate RUG payments (see p. 80).

Best practice: Approach the wound as if it's a brand new ulcer in terms of staging it according to the RAI User's Manual staging instructions every time you do an MDS assessment, advises Nathan Lake, RN, BSN, MSHA, an MDS and long-term care expert in Seattle. But in the medical record documentation, refer to the wound as a Stage 4 (if that's what it was) that now looks like a Stage 2 for coding purposes on the MDS, he adds.

Reasoning: You don't want to lose track of the fact that the ulcer was in the muscle tissue, which isn't true of a Stage 2, Lake says. Or a Stage 4 could have included bone involvement. A healed Stage 4 (that area of the skin) will always be more vulnerable to pressure, he adds.

Good news: By all indications, the problems with coding wounds on the MDS 2.0 will be eliminated on the MDS 3.0, says Shephard. "The instrument will supposedly only require staging of pressure ulcers, and it looks like a listing for other problems, such as diabetic ulcers and circulatory ulcers, will be on the form," she says.